Provider Demographics
NPI:1932318730
Name:NIDO, LARISA
Entity Type:Individual
Prefix:MRS
First Name:LARISA
Middle Name:
Last Name:NIDO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 BRIGHTON BEACH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-5572
Mailing Address - Country:US
Mailing Address - Phone:718-996-6978
Mailing Address - Fax:
Practice Address - Street 1:1120 BRIGHTON BEACH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-5572
Practice Address - Country:US
Practice Address - Phone:718-996-6978
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022950124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist